Early discharge after major gynaecological surgery: advantages of fast track surgery

doi:10.4236/ojog.2011.11001

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Open Journal of Obstetrics and Gynecology, 2011, 1, 1-5

doi:10.4236/ojog.2011.11001 Published Online March 2011 (http://www.SciRP.org/journal/ojog/ OJOG

Published Online March 2011 in SciRes. http://www.scirp.org/journal/OJOG

Early discharge after major gynaecological surgery:

advantages of fast track surgery

Jonathan Carter1,2, Shannon Philp1,2, Vive k Ar or a1

1Sydney Gynaecological Oncology Group, Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, Australia

2The University of Sydney, Sydney, Australia

Email: [email protected]

Received 20 February 2011; revised 21 March 2011; accepted 28 March 2011.

ABSTRACT

Introduction: Fast Track Surgery (FTS) programs

have been adopted by many specialties with docu-

mented improved patient outcomes and reduced

length of stay (LOS). Methods: We initiated a FTS

program in January 2008 and present our experience

up to and including November 2010 on patients whose

LOS was 2 days. Results: During the study period

242 patients had a laparotomy performed. Overall 54

(22.3%) patients were discharged on day 2. In the

first year of initiating our FTS program 10% were

discharged on day 2, 25% in year 2 and 31% in year

3. Twenty-two patients (41%) had malignant pathol-

ogy and of these, 16 (73%) had local or regional

spread and 6 (27%) had distant spread. Forty pa-

tients (74%) had vertical midline incisions (VMI)

performed. Surgery was classified as complex in 40

cases (74%) and 6 (11%) patients underwent staging

lymph node dissection. Av erage patient BMI was 26.1

with 44% of patients considered overweight or obese.

There were no intraoperative complications recorded.

When compared to 188 patients whose LOS was

greater than 2 days, the early discharge cohort were

more likely to have benign pathology, more likely to

be younger, to have a transverse incision, to have re-

ceived COX II inhibitors, to have a lower net haemo-

globin (Hb) change and to tolerate early oral feeding.

Conclusions: Increased clinical experience with FTS

enables over 31% patients undergoing laparotomy to

be safely discharged on day 2 without an increase in

the readmission rate or morbidity.

Keywords: Fast Track Surgery; Gynaecology; Oncology

1. INTRODUCTION

In contemporary surgical care patients would often be

admitted to hospital the day prior to planned surgery,

undergo preoperative mechanical and antibiotic bowel

preparation and have IV fluids running to keep them in

fluid balance, prior to any surgical or anaesthetic insult.

Intraoperatively patients were often volume loaded to

maintain a filling pressure, had nasogastric tubes in-

serted, as well as pelvic drains to prevent development

of collections, then spent 2 - 3 days nil by mouth (NBM)

until bowel sounds were heard before b eing commenced

on a graduated diet of clear liquids, free fluids, light diet

and finally commenced on a regular diet 5 - 7 days post

surgery. Patients were then discharged, on average 5 - 7

days post surgery [1] .

Fast Track Surgery (FTS) or Enhanced Surgical Re-

covery (ESR) programs have been developed and re-

fined in many specialties with documented improved

patient outcomes and as a consequence earlier discharge

form hospital and reduced length of stay (LOS) [1-5].

The aim of this study is to identify patients following

a FTS program [6] who have been discharged earlier

than anticipated, being day 2 post op after major gynae-

cological/gynaecological oncologic surgery and analyse

elements that may have aided in their early discharge.

2. METHODS

After Ethics approval was granted the FTS Database was

searched to identify patients operated upon by laparo-

tomy between January 2008 and November 2010 and

whose LOS was 2 days. Data was collected in a real time

fashion and analysis undertaken in a retrospective fash-

ion.

Our FTS protocol commences with preoperative pa-

tient counseling regarding the program. Patients are

made aware that their anticipated LOS is 3 days, that

narcotic analg esia will be limited and adequ ate analgesia

provided by a combination of intraoperative paracoxib

+/- transverse abdominis plane (TAP) block [7]. Post-

operatively meloxicam is prescribed for 3 days with

regular paracetamol. Early oral feeding by way of oral

liquids are allowed on the night of surgery and patients

are commenced on a light diet on post op day 1 with

rapid progression thereafter. If significant abdominal

J. Carter et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 1-5

distension or vomiting develops oral feeding is ceased.

Movicol or Colo xyl with Senna is commenced routinely

on post op day 1 and continued post discharge. All pa-

tients received perioperative Clexane 20 mg - 40 mg SCI

which is continued until discharge. Intraoperatively me-

chanical sequential compression devices are employed

and all patients have knee high TED stockings fitted

preoperati vel y and are worn postoperatively for at least 1

month. Patients are mobilized on day 1 post surgery and

catheters and IV fluids are removed on day 1 whenever

possible. Patients are given an incentive spirometer and

encouraged to use the device 6 times per hour. Criteria

for discharge include the patient 1) adequately mobiliz-

ing without assistance, 2) tolerating ear ly oral feeding, 3)

having pain and discomfort controlled by oral analgesia

and 4) having adequate home supervision after discharge.

Post discharge patients receive a follow up phone call

from our Clinical Nurse Consultant (CNC) within 3 days

of discharge.

Data collected relate to 1) patient characteristics, 2)

hospitalisation and 3) post-hospitalization. The patient

characteristics collected were: age, weight, height, body

mass index (BMI), medical insurance status and per-

formance status. Hospitalization details included the pro-

cedure performed, type of incision (transverse or mid-

line), operating time, complexity of surgery (simple vs.

complex), intraoperative estimated blood loss, wh ether a

transfusion was required, the preoperative Hb, post op-

erative Hb and the Hb change, whether the patient suc-

cessfully completed early oral feeding and if the patient

received COX II inhibitors. All inpatient complications

were collected, including modified Royal Australian and

New Zealand College of Obstetricians and Gynaecolo-

gists (RANZCOG) Quality Indicators. LOS was calcu-

lated by the difference between date of discharge and

date of surgery. Post hospitalisation admissions and

complications were also recorded.

Simple surgery was defined as benign low risk ad-

nexal surgery or simple type 1 hysterectomy where for-

mal ureteric dissection was not performed. All surgeries

where formal pelvic sidewall dissection was undertaken

were classified as “complex”. Transverse incisions were

classified according to the incision in the skin, irrespec-

tive of whether it was of Maylard type or Pfannenstiel.

Pathologically patients were classified on final patho-

logical determination as either “benign” or “malignant”.

Patients with proliferating or borderline ovarian tumours

were classified as “benign”. Patients with malignant pa-

thology were routinely reviewed 2 weeks postopera-

tively and then regularly thereafter, whilst those patients

with benign pathology were reviewed 2 - 4 weeks post

operation.

According to International Standards, a BMI of 25 -

29.9 was considered overweight and >30 obese. Statisti-

cal analysis including descriptive statistics, t-test and

ANOVA for nominal variables and chi-squared test for

categorical data.

3. RESULTS

During the study period 242 patients had a laparotomy

performed by the author (JC). Fifty-four (22.3%) pa-

tients overall were discharged on day 2. In year 1 after

initiating the program 10% were discharged on day 2,

25% in year 2 and 31% in year 3 (Table 1).

Of those discharged on postop day 2, their average

age was 47.6 years (Range: 20 - 74), with 25 (46%) pa-

tients older than 50 years. Twenty two patients (41%)

had malignant pathology and of these 14 (25.9%) had

FIGO stage I disease, 2 (3.7%) had FIGO stage II dis-

ease, 4 (7.4%) had FIGO stage III disease and 2 (3.7%)

patient had FIGO stage IV disease. Sixteen (73%) had

local or regional spread and 6 (27%) had distant spread.

Thirty one patients (57.4%) had ovarian pathology, 15

(27.8%) uterine pathology, 6 (11.1%) cervical pathology

and 2 patients (3.7%) had other pathology. Thirty five

patients (65%) had private medical insurance and 40

patients (74%) had VMI perfo rmed.

The mean operating time was 1.91 hours (Range : 0.92

hours - 3.3 hours). Two surgeries (4%) lasted less than 1

hour, 33 lasted less than 2 hours (61%) and 18 surgeries

(33%) lasted less than 3 hours and 1 surgery less than 4

hours.

Surgery was classified as complex in 40 cases (74%)

and 6 (11%) patients underwent staging lymph node

dissection.

Average patient weight was 68.95 kg with mean BMI

26.1 (range 17.5 - 44.5). Thirty patients (56%) were

classified as normal BMI, 11 (20%) as overweight and

13 (24%) as obese.

There were no blood transfusions and mean EBL at

surgery was 196 mL (Range: 10 mL - 900 mL) and the

mean Hb change was 8. 3 g/L.

All patients were successfully fast tracked and toler-

ated early oral feeding, 51 (94%) prescribed COX II in-

hibitors and 50 (93%) had a “0” performance status de-

scribed as “fully active”. Four patients (7%) had a per-

formance status of “1”, described as “light restrictions”.

There were no intraoperative complications recorded.

One patient developed a wound infection and was read-

mitted 2 weeks post op. Two patients were transfused

Table 1. Incidence of discharge on day 2 post laparotomy

compared with years after initiation of FTS.

Year 1 Year 2 Year 3

D/C Day 27/73 (10%)25/99 (25.3%) 22/70 (31.4%)

J. Carter et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 1-5 3

both had benign disease and severe menorrhagia. One

was transfused both pre and post op and the second just

postoperatively. One patient developed femoral neuro-

praxia that settled prior to disch arge and one patien t was

a laparoscopic conversion after failed laparoscopic hys-

terectomy. One patient was diagnosed post discharge

with a symptomatic PE. She was a 74 yr old woman with

a BMI of 38 with recurrent low grade uterine sarcoma

with a large mass. She was admitted for attempted de-

bulking but was found to have unresectable, fixed pelvic

disease. An omental biopsy o n l y was performed.

When compared to 188 patients whose LOS was

greater than 2 days, the early discharge cohort were

more likely to have benign pathology (P < 0.002), to be

younger (P < 0.000 1), under age 50 (P = 0.007), have a

transverse incision rather than VMI (P = 0.000 2), have

simple surgery performed (P = 0.01), shorter operating

times (P = 0.000 1), receiving COX II inhibitors (P =

0.04), more likely to have a “0” performance status (P =

0.002), a lower net Hb change (p = 0.01), and more

likely to tolerate early oral feeding (p = 0.02) (Table 2).

There was no difference in tumour site, medical insur-

ance status, BMI, proportion of overweight or obese

patients, intraoperative transfusions, EBL at surgery, or

complication rate

4. DISCUSSION

The improvement in surgical outcomes demonstrated in

FTS programs has allowed as a consequence a reduction

in the hospital LOS. This study has demonstrated that

with experience, 1 in 3 patients undergoing a laparotomy

for gynaecological surgery can be discharged on day 2

post surgery, without an increased morbidity or readmis-

sion rate [8,9].

Whilst it is probably unrealistic to exp ect the LOS af-

ter laparotomy to be further reduced from 2 days, it is

realistic to expect that with further refinements and en-

hancements to FTS programs a greater proportion of

patients can expect a safe discharge on day 2. With in-

creasing experience of our team, and the appointment of

a dedicated Fast Track Clinical Nurse Consultant (CNC),

we have been able to increase the percentage of patients

discharged on day 2 from 10% in the first year of the

program to 25% in the second year an d 31% in the third

year after initiating a FTS program.

These improvements do not appear to be restricted to

simple surgical cases in thin women, who have had

transverse incisions and who lack private medical insur-

ance. To the contrary, our data shows that 24 (44%) pa-

tients discharged on day 2 were considered overweight

or obese, 40 (74%) had complex procedures performed,

35(65%) had private medical insurance and 40 (74%)

had vertical midline in cisions.

Table 2. Comparison of patients discharged on day 2 with

those discharged after day 2.

Discharge

= Day 2

(N = 54)

Discharge

>Day 2

(N = 188) Significance

Age

Mean 47.6 56.1 P < 0.000 1

<50 29 (53.7%) 63 (33.5%) P < 0.01

Performance

Fully Active 49 (92.5%) 133 (70.7%) P < 0.001

Pathology P < 0.002

Benign 32 (59.3%) 67 (67.7%)

Malignant 22 (40.7%) 121 (64.4%)

Stage

Stage I 14 (25.9%) 65 (34.6%) P = 0.01

Stage II 2 (3.7%) 6 (3.2%)

Stage III 4 (7.4%) 42 (22.3%)

Stage IV 2 (3.7%) 8 (4.3%)

Incision

Transverse 14 (25.9%) 13 (6.9%) P < 0.000 1

VMI 40 (74.1%) 175 (93.1%)

Operating Time

Mean 1.91 2.43 P < 0.000 1

Complexity

Simple 14 (25.9%) 23 (12.2%) P < 0.01

Complex 40 (74.1) 165 (87.8%)

EBL

Hb Change 8.3 g/L 11.3 P < 0.04*

COX II 51 (94.4%) 157 (83.5%) P = 0.02

Tolerate EOF 54 (100%) 165 (87.8%) P < 0.006

*Assuming equal variances.

Whilst not following FTS protocols as defined by

Kehlet et al [1], Chase and colleagues are to be com-

mended in reporting the largest series of gynaecologic

surgical patients treated by a standard clinical pathway.

Clinical pathways encompass some but not all of the

elements essential to a FTS program. With 880 patients

operated upon over a 7-year period, they found younger

age, lower BMI, lower EBL at surgery, a post operative

diagnosis of benign ovarian neoplasm and non-radical

dissection significant factors for early discharge [10]. In

this series an incredible 322 patients (37%) were able to

J. Carter et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 1-5

be discharged on day 2, setting the benchmark for all

others following the principals of FTS to aspire to. Our

findings are similar to Chase et al, in that younger age,

ovarian tumours, benign pathology, transverse skin inci-

sions, decreased operating time, early oral feeding, use

of COX II inhibitors and net haemoglobin change were

all significantly different in the early discharge group

when compared to the group of patients discharged after

day 2. In addition, with our greater experience, we have

found in our third year after adopting FTS principles,

31.4% of our patients can now be discharged on day 2.

We did not find insurance status, weight, BMI or esti-

mated blood loss to be significantly different between

the groups.

Both Chase et al and our own group have questioned

the reported perceived benefits of laparoscopic surgery

in light of results achieved with FTS laparotomy [6,10].

Recent evidence from the GOG LAP2 study support our

position. This is the largest prospective randomized

study in the world comparing laparoscopic surgery for

endometrial cancer to non-fast tracked laparotomy pa-

tients. In summary there were similar rates of in-

tra-operative complications, with a significant number of

patients converted to laparotomy due to poor visibility,

metastatic cancer or bleeding. Median LOS of non-fast

tracked laparotomy patients was 4 days and 3 days for

laparoscopy patients [11]. Furthermore, whilst quality of

life (QOL) was enhanced across many parameters in the

laparoscopy group at 6 weeks, these differences were not

significant by 6 months. Whilst cross trial comparisons

are statistically invalid, one can only speculate whether

the 1 day difference in LOS would be negated if the

laparotomy patients in this study were fast tracked [12].

Similar results have also b een publish ed by Mouritis and

colleagues [13] who have reported a median LOS of 5

days for their non-fast tracked hysterectomy patients

compared to 2 days for laparoscopic hysterectomy pa-

tients and no difference in major complication rate.

Further enhancements to our FTS program which will

allow a greater proportion of patients to be safely dis-

charged on day 2 include enhancing preoperative con-

sultations to further emphasise the rationale of FTS and

encouraging patients to contribute by agreeing to dis-

charge when medically appropriate. A number of our

patients discharged on day 3 could have been discharged

on day 2 had there been appropriate supervision at home

on discharge. Improving GI function is also an area we

have identified as worthy of further study. Simple tech-

niques such as initiating a regular chewing gum regimen

after surgery to stimulate bowel function has been sh own

to be effective and would add little financial impost and

minimal risk of increased morbidity [14-19]. Health care

organisations and Hospital Administrators also derive

significant financial benefit from a FTS program and

should provide funding for the initiation and mainte-

nance of such programs.

This study has shown that with experience over 30%

patients undergoing laparotomy on a FTS program, can

be safely discharged on day 2 without an increase in the

readmission rate or morbidity.

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